剖宫产腰麻相关进展

剖宫产腰麻相关进展,Advances in Spinal Anesthesia forC-section,背景,腰麻是产科麻醉的最主要方式之一腰麻的临床并发症不少腰麻的临床应用存在不规范的现象腰麻相关的争议点不少腰麻相关的新观点,产科腰麻应用广泛,效果确切,起效快,用药量少,操作相对简单,广泛应用,背景,腰麻是产科麻醉的最主要方式之一腰麻的临床并发症不少腰麻的临床应用存在不规范的现象腰麻相关的争议点不少腰麻相关的新观点,腰麻相关问题,穿刺点选择及定位腰麻药物的比重腰麻药物的种类选择腰麻后头疼的防治腰麻后低血压的血管活性药物应用腰麻后神经并发症,腰麻相关问题,穿刺点选择及定位腰麻药物的比重腰麻药物的种类选择腰麻后头疼的防治腰麻后低血压的血管活性药物应用腰麻后神经并发症,常用穿刺间隙及定位,常用穿刺点L2-3,髂后上棘连线Intercristal Line,圆锥终止点 L1,肩胛下角连线,Position of conus medullaris in 100 patients with MRI scans.,Anaesthesia, 2000,55, 1122-1126,脊髓圆锥位置,脊髓终止 于L2椎体以下,椎（间隙）定位,Anaesthetists opinion of vertebral level compared with actual markers (determined with MRI),Anaesthesia, 2000,55, 1122-1126,腰麻穿刺间隙?,In conclusion, we recommend that if a choice of suitable interspaces exists, the lower one be selected for intrathecal injection, to reduce the risk of neurological damage from either misidentification of the vertebral level or an unexpected low conus.,Anaesthesia, 2000,55, 1122-1126,人工触摸法确定脊椎间隙有误差；脊髓圆锥位置低于L2的比例不低L2-3间隙行腰麻穿刺损伤脊髓圆锥的概率高达4-20%建议腰麻穿刺点L3-4椎间隙或以下,Anaesthesia, 2001,56, 238-247,Int J Obstet Anesth, 2014,23,206-12,超声引导?,Anesth Analg, 2011;113:559-64,超声髂后上棘连线定位,Anesth Analg, 2011;113:559-64,触摸法髂后上棘连线定位,Anesth Analg, 2011;113:559-64,Distribution of the clinical estimates of the intercristal line by palpation,超声定位 vs 触摸定位,Anesth Analg, 2011;113:559-64,B 超提示髂脊连线的解剖位置至少有6%在L3或L3以上。40%的临床触摸法的定位往往比B超定位高1个节段以上,建议可选择超声指导椎间隙定位！特别是肥胖或病理肥胖孕妇,超声引导腰麻-肥胖孕妇,J Anesth (2014) 28:413419,超声引导腰麻-孕妇,超声深度与腰麻针深度,Non-obese,J Anesth (2014) 28:413419,Obese,R2=0.275,R2=0.516,Ultrasound-guided,J Anesth (2014) 28:413419,超声引导腰麻穿刺可减少腰穿次数。在肥胖病人中超声引导下首次穿刺成功率为92%，而传统穿刺法首次穿刺成功率为44%。对于预计穿刺困难的（如肥胖病人）可应用超声引导，以提高穿刺成功率，减少并发症，提高病人满意度。,Aqueous Ultrasound Gel,Reg Anesth Pain Med 2013;38: 100-105,Conclusion: Subarachnoid injection of ultrasound gel in piglets resultsin an inflammatory response within neuraxial space,腰麻相关问题,穿刺点选择及定位腰麻药物的比重腰麻药物的种类选择腰麻后头疼的防治腰麻后低血压的血管活性药物应用腰麻后神经并发症,Hyerbaric vs Isobaric,The Cochrane Library，2013，Issue 5,Hyerbaric vs Isobaric,腰麻转为全麻的比例：重比重腰麻显著低于等比重腰麻 。说明重比重腰麻麻醉效果更可靠！,Hyerbaric vs Isobaric,感觉阻滞平面到达T4的时间：重比重腰麻显著快于于等比重腰麻 。说明重比重腰麻麻醉起效更快！,Hyerbaric vs Isobaric,其他观察指标（术中加用其他镇痛药；麻黄碱用量；腰麻后头疼；恶心呕吐发生率；超高平面阻滞）：重比重与等比重腰麻 无统计学差异。,Hyperbaric Solution,其他：平面容易调控常用药物：葡萄糖最高浓度：8%（80mg/ml），3ml内加50%GS 0.30.45ml。注意：无菌！,腰麻相关问题,穿刺点选择及定位腰麻药物的比重腰麻药物的选择腰麻后头疼的防治腰麻后低血压的血管活性药物应用腰麻后神经并发症,腰麻药物的神经毒性,Curr Opin Anesthesiol 2014, 27:549555,Chloroprocaine has a lower risk for TNS than lidocaine in the clinical setting, but experimental data still do not allow us to consider the issue of chloroprocaine or bisulfide induced neurotoxicity to be resolvedPrevious work has demonstrated a higher neurotoxic potential for lidocaine, mepivacaine, bupivacaine,tetracaine and prilocaineRelative neurotoxic potential is determined to be in the following order: procainelevobupivacaineropivacaine.,Spinal Ropivacaine for CS,罗哌卡因为长效酰胺类局麻药较低的神经毒性较低的心脏毒性显著地感觉-运动神经阻滞分离特殊的包装*,Spinal Ropivacaine (safety),Can J Anesth 2012;59:456-465,Spinal Ropivacaine (safety),以大鼠为实验对象第一部分：鞘内注射110倍临床浓度（相同容量）的普鲁卡因，布比卡因，左旋布比卡因，罗哌卡因，观察神经行为学变化第二部分：鞘内注射不同容量（相同浓度）的四种局麻药，进行组织学观察,Spinal Ropivacaine (safety),Can J Anesth 2012;59:456-465,Spinal Ropivacaine (safety),Can J Anesth 2012;59:456-465,Spinal Ropivacaine (safety),Can J Anesth 2012;59:456-465,Paw stimulation test in the volume experiment expressed as apercent change in maximum possible effect (%MPE)PID4,Spinal Ropivacaine (safety),Can J Anesth 2012;59:456-465,Spinal Ropivacaine (safety),Can J Anesth 2012;59:456-465,Spinal Ropivacaine (Dose),Anesthesiology, 2001 ;95 (6)：1346-50,Anesthesiology, 2001 ;95 (6)：1346-50,Spinal Ropivacaine (Dose),Spinal Ropivacaine (Dose),Spinal Ropivacaine (Dose),Chen X et al. J Zhejiang Univ SCIENCE B 2006 7(12):992-7,Spinal Ropivacaine (Dose),Spinal Ropivacaine+Suf,Int J Obstet Anesth 2008;17:309-14,设计：单纯平行对照研究分组：实验组舒芬太尼5micg+罗哌卡因10mg 对照组罗哌卡因15mg定性研究观察指标：腰麻相关参数,Spinal Ropivacaine+Suf,Int J Obstet Anesth 2008;17:309-14,Spinal Ropivacaine+Suf,Int J Obstet Anesth 2008;17:309-14,Spinal Ropivacaine+Suf,Int J Obstet Anesth 2008;17:309-14,Spinal Ropivacaine+Suf,Int J Obstet Anesth 2008;17:309-14,Spinal Ropivacaine+Suf,Spinal Ropivacaine+Suf,Int J Obstet Anesth 2008;17:309-14,Spinal Ropivacaine+Suf,Acta Anaesthesiol Scand 2010;54:284-290,Spinal Ropivacaine+Suf,设计：序贯法半数有效剂量法分组：单纯罗哌卡因组、罗哌卡因舒芬太尼组开始剂量：实验组10mg，对照组13mg剂量间隔：0.3mg有效指标：10min内痛觉平面达且整个手术过程无须额外追加加药（硬膜外或静脉）,Rop ED50 of intrathecal hyperbaric ropivacaine for caesarean delivery is 11.24mg (CI 95%: 10.95-11.55),Rop+Suf: ED50is 8.07mg (CI 95%: 7.82-8.33),Spinal Ropivacaine+Suf,5ug 舒芬太尼能使重比重罗哌卡因腰麻 （剖宫产）的ED50 降低约28左右,Acta Anaesthesiol Scand 2010;54:284-290,腰麻相关问题,穿刺点选择及定位腰麻药物的比重腰麻药物的种类选择腰麻后头疼的防治腰麻后低血压的血管活性药物应用腰麻后神经并发症,Preventing for PDPH,The Cochrane Library，2014，Issue 2,分析了10个RCT研究，其中大部分为产妇。观察的药物有：鞘内吗啡，鞘内芬太尼，口服咖啡因，直肠消炎痛，静脉Cosyntropin（ACTH），静脉氨茶碱，静脉地塞米松等。比较的指标为：PDPH发生率，瘙痒、恶心呕吐、住院日、等。,Preventing for PDPH,Caffeine vs Placebo,PDPH 发生率,Preventing for PDPH,Caffeine vs Placebo,严重PDPH 发生率,Preventing for PDPH,PDPH 发生率,Aminophylline vs No invervention,Preventing for PDPH,吗啡和促肾上腺素皮质激素（ACTH，cosyntropin）能有效降低腰麻后PDPH（各种程度）发生率，特别适合PDPH高风险患者如产科病人。氨茶碱也能降低腰麻后PDPH发生率。地塞米松增加剖宫产腰麻后PHPH风险。吗啡的主要副作用瘙痒、恶心、呕吐等。,Preventing for PDPH,腰麻相关问题,穿刺点选择及定位腰麻药物的比重腰麻药物的种类选择腰麻后头疼的防治腰麻低血压的血管活性药物的应用腰麻后神经并发症,苯肾上腺素 vs 麻黄碱,Anesth Analg 2012;114:37790,World J Clin Cases 2015 January 16; 3(1): 58-64,苯肾上腺素 VS 麻黄碱,两者对腰麻低血压均有效苯肾上腺素：IONV更低苯肾上腺素：脐血酸血症少（临床意义？）麻黄碱：CO更高（临床意义？）目前：苯肾上腺素是产科低血压防治的主流药物苯肾上腺素的理想用药模式还有待研究 预防性？连续输注？单次?,去甲肾上腺素VS苯肾上腺素,Anesthesiology 2015; 122:736-45,用药方法：计算机闭环控制输注浓度：去甲肾（5ug/ml）、苯肾（100ug/ml）速度：初始为30ml/h，然后根据血压自动调整速度【Infusion rate (ml / h) = (1